Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
Are you allergic to any of the following’?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be
dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.